Methods of intravenous administration of glyburide

ABSTRACT

The present disclosure is drawn to a method of treating a patient in need of treatment, comprising identifying a patient in need of treatment for stroke, traumatic brain injury, spinal cord injury, myocardial infarction, shock, organ ischemia, ventricular arrhythmias, ischemic injury, or hypoxia/ischemia; administering a bolus of glyburide to the patient; and administering a continuous infusion of glyburide to the patient at from about 15 μg/hr and about 300 μg/hr, wherein the continuous infusion glyburide is administered for a period of time more than about 20 hours.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of and claims priority to U.S. patentapplication Ser. No. 17/030,925, filed Sep. 24, 2020, which is acontinuation of and claims priority to U.S. patent application Ser. No.16/459,893 filed Jul. 2, 2019, now U.S. Pat. No. 10,786,445, which is acontinuation and claims priority to U.S. patent application Ser. No.15/686,989 filed Aug. 25, 2017, now U.S. Pat. No. 10,391,053, which is acontinuation of and claims priority to U.S. patent application Ser. No.15/425,874, filed Feb. 6, 2017, now U.S. Pat. No. 10,052,280, which is acontinuation of and claims priority to U.S. patent application Ser. No.15/422,358, filed Feb. 1, 2017, now abandoned, which is a continuationof and claims priority to U.S. patent application Ser. No. 14/878,232,filed Oct. 8, 2015, now U.S. Pat. No. 9,561,176, which is a continuationof and claims priority to U.S. patent application Ser. No. 14/525,992,filed on Oct. 28, 2014, now U.S. Pat. No. 9,254,259, which is acontinuation of and claims priority to U.S. patent application Ser. No.13/811,037, filed on Mar. 21, 2013, now U.S. Pat. No. 8,946,293, whichwas a National Stage Entry under 35 U.S.C. § 371 of InternationalApplication No. PCT/US2011/044397, filed Jul. 18, 2011, which claimedpriority under 35 U.S.C. § 119(e) and the benefit of U.S. ProvisionalApplication Ser. No. 61/365,689, filed Jul. 19, 2010, the entiredisclosures of which are hereby incorporated by reference in theirentireties.

FIELD OF THE INVENTION

This invention relates to the field of medical treatment methods,including intravenous methods of administration of drugs to a subject.

BACKGROUND

Glyburide (also known as, e.g., glibenclamide) is a sulfonylurea drugused in treating diabetes. The systematic name of glyburide is5-chloro-N-(4-[N-(cyclohexylcarbamoyl)sulfamoyl]phenethyl)-2-methoxybenzamide. Glyburide preferentially bindsto and affects the sulfonylurea receptor 1 (SUR1) but at higherconcentrations also binds to and affects the sulfonylurea receptor 2(SUR2).

Glyburide has been suggested as a therapy for acute stroke (ischemic andhemorrhagic), traumatic brain injury (TBI), spinal cord injury (SCI),myocardial infarction (MI), shock (including hemorrhagic shock), organischemia, and ventricular arrhythmias. The pharmacokinetic parameters ofintravenous glyburide have been described in numerous publications (seeTable 1). All patents and publications discussed herein are herebyincorporated by reference in their entireties.

TABLE 1 Pharmacokinetic Parameters of Glyburide after IntravenousAdministration Neugebauer⁷ NIDDM(Non insulin Spraul² Rydberg³ Rogers⁴Morrison⁶ dependent Jonsson^(8†) Publication McEwen¹ Healthy HealthyHealthy Sorgel⁵ Healthy diabetes Healthy Patient Healthy males and malesand males and Healthy males and mellitus) males males and Populationmales females females females males females and females females N 20 52 8 8 24   8  20  10 Dose (mg)  1.48^(‡)  4.0  1.0 1  1.5   2.4   1.25  2.0 C_(max) (ng/ml) — — — — 331 ± 65 648 376 196 Clearance:  2.92^(‡)—  5.46*^(‡) — —   4.42   4.41   1.68^(‡) (L/b) (mL/min) 49 — 91*^(‡) — 74.7 ± 22  73.7^(‡)  73.5^(‡) 101.3 V_(d) (L)  9.7^(‡) — 10.9*^(‡) —11.22 ± 3   7.4  11.6^(‡) — Beta (1/h) 0.3 —  0.52*^(‡) 0.517 —   0.62  0.38 — t_(1/2) (h)  2.46 1.50 ± 0.36 1.47 ± 0.42 1.47 4.22 ± 1  1.18^(‡)   1.82   1.15 Tmax(h) — — — —  0.09 — — — Mean subject  74.1— 74.6 57-88  4  69.7 — — weight (kg) *normalized to 70 kg ^(†)Data fromCaucasian patients ^(‡)Not presented in the publication, data generatedfrom information presented in the publication. AUC, area under thetime-concentration curve; C_(max), the maximum concentration of thedrug; V_(d), the volume of distribution of drug ¹McEwen, et al. 1982;²Spraul et al. 1989; ³Rydberg et al. 1995; ⁴Rogers et al. 1982; ⁵Sorgelet al. 1997; ⁶Morrison et al. 1982; ⁷Neugebauer et al. 1985; ⁸Jonsson etal. 2000.

While the intravenous (“i.v.” or “IV”) glyburide dose in these and otherstudies was delivered within a few minutes in the majority of studies,several of the studies included continuous infusions of an hour or more.Garrel et al. (1987) administered a 1 mg i.v. bolus dose, followed by0.3 mg/h for 17 hours, to six subjects with IDDM (insulin-dependentdiabetes mellitus); the total dose was 6.1 mg glyburide. In addition,Groop et al. (1987) dosed 16 normal subjects with a total of 2.1 mg over4 hours, and Neugebauer et al. (1985) dosed ten normal subjects with atotal of 2 mg i.v. glyburide over 1 hour.

Doses for bolus infusions (i.e., infusions of three minutes or less)ranged between 1 and 2.4 mg (Rydberg et al. 1994).

The doses and duration of dosing of the studies described above arepresented in Table 2.

TABLE 2 Dose and Duration of Dosing in Select Clinical Studies ofIntravenous Glyburide. Garrel et al. Groop et al. Neugebauer Rydberg etBank et al. 1987 1987 et al. 1985 al. 1994 2000 N 6 16 10 8 12 Bolusdose 1 mg 0.84 mg N/A 2.4 mg — Duration of 17 hours 4 hours 1 hour — 10min infusion Infusion 0.3 mg/hr 0.35 mg/hr 2 mg/hr — 6 mg/hr dose/hrBolus dose 1 mg 0.84 mg N/A 2.4 mg — Total dose 6.1 mg 2.1 mg 2 mg 2.4mg 1 mg

Maximum glyburide plasma concentrations were provided for some studies,and ranged from 200-436 ng/mL (Rogers et al. 1982; Groop et al. 1987;Bank et al. 2000; Jonsson et al. 2000). Subjects in the study by Groopet al. (1987), who received a bolus dose followed by continuous i.v.infusion, reached a mean glyburide C_(max) of 240 ng/mL afteradministration of the bolus, and a steady-state concentration of 88-93ng/mL during the 220 minutes of continuous infusion.

SUMMARY OF THE INVENTION

Methods of administering glyburide, or other drug, are disclosed. Thenovel methods disclosed herein include methods of administeringglyburide, or other drug, over periods of more than an hour to asubject, and preferably over periods of many hours (e.g., about 72 hoursor about 96 hours or about 120 hours), and in particular includeintravenous methods of administering glyburide, or other drug, to asubject. The methods disclosed herein may be useful for treating asubject in need of treatment for, e.g., acute stroke (ischemic andhemorrhagic), traumatic brain injury (TBI), spinal cord injury (SCI),myocardial infarction (MI), shock (including hemorrhagic shock), organischemia, and ventricular arrhythmias. In these and other indications,the use of intravenous glyburide is preferable as targeted glyburideplasma levels can be more quickly and reliably be reached andmaintained. The methods disclosed herein provide rapid achievement oftherapeutic levels of glyburide, or other drug, following initiation ofdrug administration, and also provide for maintenance of therapeuticlevels of glyburide, or other drug, over an extended period of time,(e.g., for about 72 hours or about 96 hours or about 120 hours). Inaddition, the methods disclosed herein provide rapid achievement oftherapeutic drug levels, maintenance of therapeutic drug levels for anextended period of time, and further avoid excessive levels of drug andso avoid possible drug side-effects.

Embodiments of the methods of administering glyburide, or other drug, toa subject include intravenous administration of a bolus of glyburide, orother drug, followed (either substantially immediately, or after a delayafter completion of the bolus administration) by a continuous infusionof glyburide, or other drug. Further embodiments of the methods ofadministering glyburide, or other drug, to a subject include intravenousadministration of a first bolus of glyburide, or other drug, followed(either substantially immediately, or after a delay after completion ofthe bolus administration) by a continuous infusion of glyburide, orother drug, followed by a second bolus of glyburide, or other drug. Infurther embodiments, a second infusion may follow a second bolus. In yetfurther embodiments, multiple boluses and multiple infusions may beadministered to a subject.

In embodiments, the administration of glyburide to a subject extendsover periods of more than an hour to a subject; in particularembodiments, the methods of administration of glyburide to a subject areintravenous methods of administration of glyburide to a subject wherethe administration extends over periods of more than an hour. Forexample, in embodiments, administration of glyburide, or other drug,extends over periods of more than about 72 hours. In other embodiments,administration of glyburide, or other drug, extends over periods of morethan about 10 hours, or more than about 20 hours, or more than about 30hours, or more than about 40 hours, or more than about 50 hours, or morethan about 60 hours, or more than about 70 hours.

The methods of administration include administration of glyburide in abolus injection to a subject, where the bolus injection is administeredto the patient over a period of time of about 3 minutes or less; andwhere the bolus administration is followed by a continuous infusion ofglyburide. In embodiments, the bolus is followed substantiallyimmediately by the initiation of the continuous infusion (e.g., thecontinuous infusion commences less than one hour, or less than 30minutes, or less than 10 minutes, or less than 5 minutes, or less than 3minutes, or less than 2 minutes, or less than 1 minute, after thecompletion of the bolus administration).

In further embodiments, the methods of administration includeadministration of glyburide in a bolus injection to a subject, where thebolus injection is administered to the patient over a period of time ofabout 3 minutes or less; and where the bolus administration is followedby a continuous infusion of glyburide, or other drug, and by one or morefurther bolus injections of glyburide, or other drug. In embodiments, asecond bolus injection is administered substantially immediately afterthe completion of the continuous infusion (e.g., the second bolusadministration commences less than one hour, or less than 30 minutes, orless than 10 minutes, or less than 5 minutes, or less than 3 minutes, orless than 2 minutes, or less than 1 minute, after the completion of thecontinuous infusion). A second continuous infusion may beginsubstantially immediately after the completion of the second bolusinjection, or a second continuous infusion may begin after an extendedperiod of time after the completion of the first continuous infusion. Inembodiments, a third bolus injection may begin after the completion ofthe second continuous infusion, and may begin either substantiallyimmediately after the completion of the second continuous infusion, ormay begin after an extended period of time after the completion of thesecond continuous infusion. Similarly, a fourth, or fifth, or otherfurther bolus injection, and/or further continuous infusion may beadministered, either substantially immediately, or after an extendedperiod of time.

In further embodiments, multiple bolus injections of glyburide, or otherdrug, may be administered to a subject, without an interveningcontinuous infusion of glyburide, or other drug. In addition, in yetfurther embodiments, multiple continuous infusions of glyburide, orother drug, may be administered to a subject, without an interveningbolus injection of glyburide, or other drug. Such multiple bolusinjections, or continuous infusions, or combinations thereof, may beadministered substantially immediately after the previous injection orinfusion, or may be administered after an extended period of time afterthe previous injection or infusion. A continuous infusion provides theadministration of glyburide, or other drug, over an extended period oftime, where an extended period of time may be a period of time measuredin minutes (e.g., a few or several or many minutes), or measured inhours (e.g., a few or several or many hours), or measured in days (e.g.,a few or several or many days).

In embodiments of the methods disclosed herein, the concentration ofglyburide, or other drug, is higher in the formulation administered bybolus injection than the concentration of glyburide, or other drug, inthe formulation administered by continuous infusion.

Applicant discloses herein that the blood levels of glyburide in humansubjects typically reaches a peak level some hours following initiationof glyburide administration (e.g., after initiation of a bolus injectionof glyburide followed by a continuous infusion of glyburide to thesubject).

In a particular embodiment, Applicant discloses herein a 3 phase dosingregimen suitable for overcoming the dip in glyburide plasma levels whichoccurs several hours following the initiation of glyburideadministration. In embodiments, such a 3 phase dosing regimen comprises:

-   -   (a) a bolus followed by a second bolus followed by a continuous        infusion    -   (b) a bolus followed by an infusion at Rate 1 for A Hours        followed by an infusion at Rate 2 for the remainder of the        dosing period, where Rate 1>Rate 2 and A ranges from 1-20 hours.        (“Rate 1” refers to a first rate, and “Rate 2” refers to a        second rate, of administration of glyburide, or other drug,        typically measured as, e.g., micrograms per hour (μg/hr).)

In a further embodiment, administration of glyburide, or other drug; isprovided by 4 or more phases in the dosing regimen where multipleboluses and/or multiple infusion rates can be used. In such anembodiment, multiple rates and durations of administration are alsoprovided (e.g., a Rate 1, Rate 2, Rate 3, Rate 4, etc.; and time periodsA, B, C, etc.).

For example, Rate 1 may vary between about 15 μg/hr and about 200 to 300μg/hr (e.g., between about 16.7 μg/hr and 250 μg/hr), and Rate 2 mayvary between about 15 μg/hr and about 200 to 300 μg/hr (e.g., between16.7 and 250 μg/hr). For example, time period A may vary from about 1 toabout 10 hours, or from about 1 to about 20 hours. The total amount ofglyburide, or other drug, delivered to the subject is the sum of theamount delivered by the bolus injection(s) plus the amount deliveredduring the continuous infusion. The amount of glyburide, or other drug,delivered to the subject during continuous infusion is calculated bymultiplying the Rate times the time period (e.g., Rate 1×time period A).In embodiments, the daily dose (the dose over a 24 hour period, forexample, the dose for the first 24 hours of glyburide administration)may be determined as follows: first Bolus+Rate 1×A+Rate 2×(24−A). Inembodiments, the dose for the first 24 hours will be less than about 6mg, or less than about 5 mg, or less than about 4 mg, and preferably maybe less than about 3.5-4 mg, or less than about 3.13 mg or less thanabout 3 mg.

Thus, in embodiments, it is preferred that the total amount of glyburideadministered to the subject per day be less than about 10 mg, or morepreferably less than about 8 mg, or more preferably less than about 6mg, and still more preferably less than about 5 mg, or yet still morepreferably less than about 4 mg, or even more preferably less than about3 mg of glyburide per day.

In a further embodiment, a bolus of about 125-150 μg, e.g., about 130μg, of glyburide is administered to a subject followed by a continuousinfusion of about 150-175 μg/hr, e.g., about 163 μg/hr, of glyburide forabout 6 hours and then a further continuous infusion of about 100-125μg/hr, e.g. about 112 μg/hr, glyburide is administered for about 50-75hours, e.g. about 66 hours, for a total dosing period of about 72 hours.Thus, in this embodiment, the total daily dose of glyburide on Day 1,Day 2 and Day 3 may be about 3-4 mg, 2.5-3 mg, and 2.5-3 mg; e.g., about3 mg, 2.5 mg, and 2.5 mg, respectively; or about 3.12 mg, 2.69 mg, and2.69 mg respectively.

In a yet further embodiment, a bolus of glyburide, or other drug, isadministered, and the bolus is followed by a continuous infusion ofglyburide, or other drug, and then a further bolus or further bolusesis/are administered, effective to raise early plasma levels ofglyburide, or other drug, to desired levels. For instance, such anembodiment of the methods disclosed herein would include administrationof a bolus of 125-150 μg, e.g., about 130 μg, glyburide followed by acontinuous infusion of 100-125 μg/hr, e.g., about 112 μg/hr ofglyburide, with a second glyburide bolus of 125-150 μg, e.g., about 130μg, administered at hour 1, 2, or 3. In embodiments, further boluses maybe administered as well.

In a further embodiment, Applicant discloses herein a method ofadministering glyburide, or other drug, to a subject, comprising: (a) abolus administration of glyburide, or other drug; (b) a first continuousinfusion administration of glyburide, or other drug after said bolusadministration of glyburide, or other drug, wherein in said firstcontinuous infusion glyburide, or other drug, is administered at a firstrate of administration for a first period of time; and (c) a secondcontinuous infusion administration of glyburide, or other drug aftersaid first continuous infusion of glyburide, or other drug, wherein insaid second continuous infusion glyburide, or other drug, isadministered at a second rate of administration for a second period oftime; whereby glyburide, or other drug, is administered to a subjecteffective to provide a substantially steady level of glyburide, or otherdrug, in the blood of said subject over a desired period of time. In aparticular example of this further embodiment, the bolus is a bolus ofabout 125-150 μg, e.g., about 130 μg, of glyburide, and the bolus isfollowed by a continuous infusion of about 150-175 μg/hr, e.g., about163 μg/hr of glyburide for about 6 hours; and then a further continuousinfusion of about 100-125 μg/hr, e.g., about 112 μg/hr glyburide isadministered to the subject for about 66 hours, for a total period ofglyburide administration of about 72 hours. The total daily dose ofglyburide on Day 1, Day 2 and Day 3 is thus about 3 mg, 2.5 mg, and 2.5mg respectively; or about 3.12 mg, 2.69 mg, and 2.69 mg respectively.

Dosing of glyburide, or other drug, may be determined as a function of asubject's weight, or age, or gender, or height, or body surface area, ora combination of one or more of these, and the rates and bolus may beexpressed as a function of one or more of these measures or methods ofdosing.

The methods disclosed herein provide advantages for treating subjects inneed of a fairly steady amount of glyburide introduced rapidly andmaintained over an extended period of time (e.g., for up to about 72hours). For example, where a subject has suffered a stroke, or traumaticbrain or spinal cord injury, rapid achievement of therapeutic levels ofglyburide may be important to a successful therapeutic outcome; inaddition, maintenance of such therapeutic levels may likewise beimportant to a successful therapeutic outcome; however, it may also beimportant to prevent sustained levels of glyburide that are too high forthe subject (e.g., to avoid hypoglycemia, extensive action of glyburideon the SUR2 receptor, or other complications). The experimental resultsand methods disclosed herein provide methods for achieving andmaintaining therapeutic levels of glyburide rapidly, and over anextended period of time, and provide methods for avoiding excessivelevels of glyburide, and so provide useful and advantageous treatmentsfor subject in need of glyburide treatment. Subject in need of suchtreatments may include, for example, subjects suffering from acutestroke (ischemic and hemorrhagic), traumatic brain injury (TBI), spinalcord injury (SCI), myocardial infarction (MI), shock (includinghemorrhagic shock), organ ischemia, and ventricular arrhythmias.

It will be understood that other drugs, in addition to glyburide, may beadministered to a subject according to the methods disclosed herein.Administration of such other drugs may be particularly advantageouswhere the other drug has a pharmacokinetic profile similar to that ofglyburide, as disclosed herein, or shares some of the pharmacokineticproperties of glyburide.

Applicants have discovered that it is preferable to avoid contact of aglyburide solution with polyvinyl chloride (PVC), as Applicants havediscovered that the concentration of glyburide is reduced in glyburidesolutions placed in contact with PVC. Applicants have invented methodsto minimize such reductions of the concentration of glyburide inglyburide solutions placed in contact with PVC, and have inventedmethods of administration of glyburide which avoids contact of glyburidesolutions with PVC. For example, Applicants have discovered that use ofpolyethylene bags, tubing, and filters, or polyethylene-coated bags andtubing, is preferred for the administration of glyburide solutions overthe use of PVC-containing bags, tubing and filters.

Applicants disclose herein methods of preparing a container or deviceused in the administration of glyburide, e.g., in the administration ofa therapeutic glyburide solution to a patient in need of such atherapeutic solution, are provided herein. Such methods of preparing acontainer or device, such as preparing a container, tube, and/or filter,comprise contacting a container, a tube, or a filter with a glyburideflushing solution. Such methods may include, for example, flushing acontainer, tube and/or filter with said glyburide flushing solutionprior to its use in the administration of glyburide; the flushing mayinclude flushing with at least about 50 mL, or at least about 70 mL, ormore of the glyburide flushing solution. A glyburide flushing solutionmay have a glyburide concentration of at least about 2 μg/mL ofglyburide, or about 2 μg/mL to about 8 μg/mL of glyburide, or about 5 to6 μg/mL of glyburide, or greater concentrations of glyburide. Suchmethods include use of containers and devices, including bags, tubes,and filters which may have polyvinyl chloride (PVC) surfaces that maycontact said glyburide therapeutic solution.

Applicants disclose herein methods of administering a glyburidetherapeutic solution, wherein a container, a tube, and/or a filter iscontacted (e.g., flushed) with a glyburide flushing solution prior touse of the container, tube, or filter in the administration of saidglyburide therapeutic solution. The flushing may be flushing with atleast 50 mL, or about 70 mL, or more, of the glyburide flushingsolution. The glyburide flushing solution may have a glyburideconcentration of at least about 2 μg/mL, or about 2 to about 8 μg/mL, ormore of glyburide. The surfaces of containers, tubes, and/or a filtersused for the administration of a glyburide therapeutic solution arepreferably made of one or more materials other than polyvinyl chloride(PVC), for example, with polyethylene, in order to avoid contact of theglyburide therapeutic solution with PVC.

Applicants further provide methods of administering glyburidetherapeutic solutions, in which a high concentration glyburide solution(e.g., at least about 10 μg/mL glyburide) is filtered and then dilutedto provide a glyburide therapeutic solution (typically of lowerglyburide concentration than the high concentration glyburide solution),and administering the glyburide therapeutic solution using deliverymeans made of one or more materials other than polyvinyl chloride (PVC),such as, e.g., polyethylene. A high concentration glyburide solution mayhave a glyburide concentration of between about 0.5 mg/mL glyburide andabout 1 mg/mL glyburide, and may have a glyburide concentration of atleast about 1 mg/mL glyburide. The glyburide therapeutic solution may bestored after filtering and prior to administration; in embodiments, thefiltered glyburide therapeutic solution is stored within a containerhaving an inner surface in contact with said glyburide therapeuticsolution, wherein said container inner surface is made from one or morematerials other than polyvinyl chloride (PVC), such as, e.g.,polyethylene.

Applicants further provide methods of treating a patient in need oftreatment, comprising identifying a patient in need of treatment forstroke, traumatic brain injury, spinal cord injury, myocardialinfarction, shock, organ ischemia, ventricular arrhythmias, ischemicinjury, or hypoxia/ischemia; administering a bolus of glyburide to thepatient; and administering a continuous infusion of glyburide to thepatient at from about 15 μg/hr and about 300 μg/hr, wherein thecontinuous infusion glyburide is administered for a period of time morethan about 20 hours.

It will be understood that solutions discussed herein, such as glyburidesolutions, and including without limitation, glyburide therapeuticsolutions, glyburide flushing solutions, high concentration glyburidesolutions, and other solutions may be filtered, and that such filteringis preferably sterile filtering, effective to provide sterile solutionssuitable for administration to a patient. Such sterile filtration mayinclude, for example, filtration through a sterile 0.2 micron filter, orother sterile filter suitable for use in providing sterile filteredsolutions.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 —Mean plasma glyburide concentrations for 0.4 mg/day glyburide.

FIG. 2 —Mean plasma glyburide concentrations for 3 mg/day glyburide.

FIG. 3 —Mean plasma glyburide concentrations for 6 mg/day glyburide.

FIG. 4 —Mean plasma glyburide concentrations for 10 mg/day glyburide.

FIG. 5 —Median blood glucose levels for placebo (0 mg/day glyburide),0.4 mg/day glyburide, and 3 mg/day glyburide.

DETAILED DESCRIPTION OF THE INVENTION Definitions

Terms used herein would be understood by those of skill in the art, andare to be understood in the manner accepted by those of skill in theart. Further definitions are provided herein to further explain anddefine terms.

As used herein, “patient,” “volunteer,” “subject” and the like, whethersingular or plural, refers to human patients, volunteers, subjects, andthe like.

As used herein, “ALT” is an acronym and means alanine transaminase.

As used herein, “AST” is an acronym and means aspartate transaminase.

As used herein, the term “dose” and its grammatical equivalents refer tothe amount of glyburide administered to a subject. A dose may bedescribed in terms of the grams of glyburide, or in terms of theweight/volume of diluent administered to the subject (e.g., milligramsper milliliter: mg/mL; micrograms per milliliter: μg/mL; nanograms permilliliter: ng/mL; etc.). The glyburide may be in water, such as sterilewater for injection or other suitable water; in saline; in sugarsolution; or in any pharmaceutically acceptable solution, which mayinclude any other pharmaceutically acceptable drugs, excipients,osmoticants, diluents, buffers, preservatives, or other compounds oradditives suitable for use in a fluid for injection.

As used here, the term “C_(max)” indicates the maximum concentration, inthe blood, of glyburide.

As used here, the term “AUC” indicates area under the curve (theintegral of the plasma concentration of the drug over an interval oftime), and is used as a measure of the total amount of glyburide, orother drug, to which the subject is exposed by the drug administration.

As used here, the term “clearance” refers to the loss of glyburide, orother drug, from the blood of the patient. Clearance refers to afraction of a (theoretical) volume of plasma from which the drug hasbeen completely removed, per unit of time. Clearance may be measured,for example, in liters per hour (L/h), in milliters per minute (mL/min).

As used herein, the term “V_(d)” refers to volume of distribution, aterm known to those of skill in the art, which refers to the volume (orpotential volume) into which a drug, such as glyburide, would bedistributed in a subject's body if it were distributed homogeneously(i.e., at the same concentration throughout that volume). Volume ofdistribution is typically measured in liters or liters per kilogram (Lor L/kg).

As used herein, the term “Beta” provides a measure of the rate oftransport of a drug, such as glyburide, into or out of the blood andtissue of a subject.

As used herein, the term “t₀” or “t_(zero)” refers to the initial time,from which further time measurements are taken. For example, whereglyburide or other drug is administered to a subject, the time t₀ is thetime at which administration commences. This initial time, the time t₀,is the time at which administration commences whether the administrationis bolus administration, continuous infusion, bolus administrationfollowed by continuous infusion, administration with periods of time inwhich no drug, or different amounts of drug, are administered, orcombinations of these.

As used herein, the term “t_(1/2)” refers to the half-life, typicallymeasured in hours (h), minutes (min) or seconds (s), of a drug that hasbeen administered to a subject. For example, the time to which the level(e.g., concentration) of glyburide or other drug (in the blood of asubject to which glyburide or other drug has been administered) drops tohalf its previous value is the t_(1/2) for that subject.

As used herein, the term “t_(max)” refers to the time to which the level(typically concentration in the blood) of a drug that has beenadministered to a subject reaches its maximum level. For example, thetime to which the level (e.g., concentration) of glyburide or other drug(in the blood of a subject to which glyburide or other drug has beenadministered) reaches its maximum after initial administration is thet_(max) for that subject.

As used herein, the term “bolus” refers to administration of glyburideor other drug in a single injection that lasts for a relatively shortperiod of time. As used herein, a bolus lasts for a period of time ofabout 3 minutes or less. A bolus injection may be an injection of arelatively high dose or concentration of drug.

As used herein, the term “continuous” refers to administration ofglyburide or other drug in an injection that lasts for an extendedperiod of time. A continuous injection may be an injection of a moderatedose or concentration of drug, or of a relatively low dose orconcentration of drug. The term “infusion” is often used with continuousinjection; as used herein, “continuous injection” and “continuousinfusion” both equally refer to the intravenous administration of adrug, such as glyburide, to a patient over an extended period of time.

As used herein, an “extended period of time” refers to a period of timethat is longer than one or two or three minutes. For example, anextended period of time may be a period of about 10 minutes, or about 20minutes, or about 30 minutes, or about 40 minutes, or about 50 minutes,or more. In further examples, an extended period of time may be a periodof about one hour, or about 2 hours, or about 3 hours, or about 4 hours,or about 5 hours, or about 6 hours, or about 7 hours, or about 8 hours,or about 9 hours, or more. In further examples, an extended period oftime may be a period of about 10 hours, or about 12 hours, or about 15hours, or about 20 hours, or about 25 hours, or about 30 hours, or about40 hours, or about 44 hours, or about 48 hours, or more. It will beunderstood that an extended period of time may also be a period of aboutone day, or about two days, or about three days, or about four days, orabout five days, or more.

As used herein, “substantially immediately” refers to a period of timethat is less than about one hour, or less than 30 minutes, or less than10 minutes, or less than 5 minutes, or less than 3 minutes, or less than2 minutes, or less than 1 minute, after a previous event or time period.

As used herein, the term “placebo” refers to an ostensiblypharmaceutical formulation which lacks a pharmaceutically activeingredient, or lacks the particular pharmaceutical ingredient ofinterest in a particular study. In the experiments disclosed herein,“placebo” refers to a formulation identical to the formulation given totest subjects but lacking glyburide (e.g., including mannitol and NaOH,but not including glyburide). In general, a placebo may include inertcompounds, and any pharmaceutically acceptable compound which may befound in a medicament, so long as it lacks a pharmaceutically activeingredient (as determined with respect to the pharmaceutical ingredientto which it is to be compared).

As used herein, the term “BG” refers to blood glucose.

As used herein, the term “PRN” means prescribed as needed.

In the following, time periods may be indicated as hours (e.g., HI0indicates at hour 10, or 10 hours following initiation of treatment) ordays (e.g., D2 indicates day 2, or the second day following initiationof treatment).

The term “DSW” as used herein indicates water with 5 grams (g) ofdextrose per 100 milliliters (mL) of water.

“RP-1127” refers to glyburide, or to glyburide formulations.

Applicant has performed experiments including the administration ofglyburide and of placebo to subjects. Results of these experiments aredisclosed in the following examples.

EXAMPLES Glyburide Storage and Administration Phase 1 Study

We determined through in-use stability testing that glyburideconcentration is reduced by contact with polyvinyl chloride (PVC). Forexample, glyburide concentration is reduced when a glyburide-containingsolution is passed through PVC tubing, or stored in a PVC bag. Forexample, we determined that glyburide concentration is reduced whenglyburide-containing solutions are stored in PVC bags at glyburideconcentrations below 10 μg/mL. One possible explanation is thatglyburide adsorbs to PVC. At 10 μg/mL glyburide we were able to use astandard PVC bag (but not PVC tubing) with an acceptable amount of lossof glyburide (e.g., loss presumably due to adsorption to PVC).

We further discovered that glyburide concentration in aglyburide-containing solution is reduced by passage though a filter,such as through a 0.2 micron in-line filter. Thus in the humanexperiments in the application, e.g., for continuous infusion, glyburidewas administered through low sorbing polyethylene (PE)-lined tubing withan inline filter that had been flushed according to a predeterminedflushing protocol (see below) designed to ensure that the concentrationof glyburide was reduced by no more than about 10%. For the lower doses,i.e. 0.4 mg/day, 3 mg/day and 6 mg/day (in which the glyburideconcentration was less than 10 μg/mL), we used PVC-free bags. For the 10mg/day dose (in which the glyburide concentration was 10 μg/mL), we usedPVC bags.

For bolus injections, at all concentrations, we used a PALL Pharmassure0.2 micron filter, HP1002 (Pall Life Sciences, 600 South Wagner Road,Ann Arbor, MI 48103) that had been flushed with the glyburide solutionto be administered (ranging from about 2-3 μg/mL to about 50-75 μg/mL,e.g., ranging from about 2.5 μg/mL to about 60 μg/mL (for example, from2.48 μg/mL to about 62.00 μg/mL) prior to use for injection.

Specifically:

-   -   The PVC free bag used was the B Braun EXCEL L8000 (B. Braun        Medical Inc., 824 Twelfth Avenue, Bethlehem, PA 18018.    -   The PVC bag used was the Viaflex 1,000 mL 2B1324X (Baxter, One        Baxter Parkway, Deerfield, IL 60015-4625).    -   The Carefusion 2260-0500 (CareFusion Corporation, 3750 Torrey        View Court, San Diego, CA 92130) low sorbing administration set        attached to an Carefusion 20350E (CareFusion Corporation, 3750        Torrey View Court, San Diego, CA 92130) low sorbing extension        set with a 0.2 micron low protein binding filter was used for        administering glyburide at 10 μg/mL concentration.    -   The Carefusion 10010454 (CareFusion Corporation, 3750 Torrey        View Court, San Diego, CA 92130) low sorbing administration set        with built in 0.2 micron filter was used for administration of        glyburide at concentrations below about 10 μg/mL.    -   An Alaris Pump unit (CareFusion Corporation, 3750 Torrey View        Court, San Diego, CA 92130) compatible with the above products        was used.

TABLE 1 Flushing Protocols for Infusion and Bolus AdministrationConcentration (ug/mL) Equipment Used Flushing with Glyburide FlushingSolution Less than 10 B Braun EXCEL Bag Prepare B Braun EXCEL bag withthe required (Infusion) L8000, Carefusion concentration. 10010454 Flushso that 120 mL is released from the distal end. administration set Wait15 minutes. with integrated filter Flush tubing with 120 mL of solution.Wait 15 minutes Flush tubing with 120 mL of solution. Wait 15 minutesAttach a newly mixed B Braun EXCEL bag of the same concentration to theadministration set, flush with 120 mL of solution immediately prior toadministration (i.e. bedside or just before dosing). Each 120 mL flushshould take at least approximately 7-8 minutes. 10.0 (Infusion) ViaflexPVC Bag, Prime so that 10 mL is released from distal end. Carefusion2260- Wait at least 10 minutes prior to use. 0500 administration Flushwith 30 mL immediately prior to administration. set plus Cardinal 20350Eextension set with filter All boluses Standard BD syringe Flush (thefilter) with 21 mL. (BD 1 Becton Drive Expel a further 7 mL. FranklinLakes, NJ Wait at least 15 minutes before use. USA 07417) with Prior toadministration, expel 2 mL. PALL 0.2 micron filter HP1002

All components and flushing protocols were extensively tested beforehandto confirm a less than about 10% reduction in glyburide passing throughthe full chain of components. A glyburide flushing solution has aglyburide concentration of at least about 2 μg/mL, or about 2-8 μg/mL,or about 5-6 μg/mL, or about 10 μg/mL, or greater.

In all cases, the catheter used was a BD Nexiva catheter (BD, 1 BectonDrive, Franklin Lakes, NJ USA 07417); the catheter was not flushed ortested.

Phase 2 Study

In the treatment of acute diseases, it is not typically desirable tospend time extensively flushing filters and tubing prior toadministration, while a patient is awaiting treatment. Thus, since timeis often of the essence in clinical situations, such as acute stroke,spinal cord injury, brain trauma, or other brain or nervous systeminjury or myocardial infarction or ventricular arrhythmias, delaying theadministration of a drug to a patient while the pharmacy flushes tubingis not a desirable option. Furthermore, in urgent or emergencysituations, it is preferable that a pharmacy have a simple set ofinstructions to prepare the drug.

Thus, although it may be possible to perform extensive flushing prior tostorage of bags and tubing for later use, such a strategy is notpreferred, since the stability of glyburide in such a situation has notbeen determined, and for sterility and other purposes, clinicians mayprefer fresh bags and tubing to bags and tubing stored for long periodsof time after flushing with glyburide, and pharmacies may prefer to haveall its tubing and bags available for use for all drugs, withoutpre-treatment with glyburide.

We performed preclinical experiments to determine whether it waspossible and practical to filter the concentrated reconstitutedglyburide material (1 mg/mL) with a 0.2 micron filter (for example theMillex 0.22 um Durapore PVDF filter SLGV033RS or SLGVM33RS (Millipore,290 Concord Road, Billerica, MA 01821), or the PALL 0.2 micron filter,HP1002) without undue loss of glyburide to the filter. In theseexperiments, the filtered material was diluted into a PVC-free bag (forexample, the B Braun EXCEL L8000). In this protocol, the filteredglyburide solution in the PVC-free bag is ready for administration to apatient through unfiltered polyethylene lined tubing (for example theCarefusion 2260-0500 or Carefusion C20014) or through polyethylene linedtubing that is substantially PVC-free i.e. has only a short section ofPVC, for example the Hospira 11993-78 (275 North Field Drive, LakeForest, Illinois 60045). Note that prior to glyburide administration,the tubing may optionally be flushed with one flush of about 50 mL toabout 75 mL (e.g., about 70 mL) of glyburide flushing solution(glyburide concentration of at least about 2 μg/mL, or about 2-8 μg/mL,or about 5-6 μg/mL, or about 10 μg/mL, or greater).

Glyburide has been administered to two patients with such a procedure.In one case, the SLGVM33RS syringe filter and the 2260-0500administration set with 6×C20014 extension sets attached to it wereused. In the other case, the SLGV033RS syringe filter and the Hospira11993-78 administration set with 6×C20014 extension sets attached to itwere used.

Pre-clinical testing shows that this procedure is effective to reducethe loss of glyburide from glyburide solutions.

We found that methods of filtering a glyburide solution that includes aglyburide concentration that is sufficiently high (e.g., at least about10 μg/mL, preferably between about 0.5 and about 1 mg/mL and even morepreferably about 1 mg/mL or greater) so that the filtering process doesnot significantly decrease the glyburide concentration, and thendiluting the solution into a PVC-free bag to provide sufficient volumeof solution to allow administration through a standard intravenous (IV)pump, then administering the solution through a filter-less polyethylenelined administration set (or a set that is mostly polyethylene linedwith a short PVC section) are effective to provide clinically effectiveconcentrations of glyburide for administration to a patient in need ofglyburide treatment. Patients in need of glyburide treatment includepatients suffering from stroke, such as acute stroke (ischemic andhemorrhagic), traumatic brain injury (TBI), spinal cord injury (SCI),myocardial infarction (MI), shock (including hemorrhagic shock), organischemia, ventricular arrhythmias, ischemic injury; hypoxia/ischemia;and other injuries, conditions, and disorders.

A BD catheter containing BD Vialon™ material was used for both patients(BD, 1 Becton Drive, Franklin Lakes, NJ USA 07417); the catheter was notflushed or tested.

Pharmacokinetic Data

Healthy volunteers were enrolled into a Phase 1 study of RP-1127 titled“A Phase I Randomized, Double-blind, Placebo-controlled Study to Assessthe Safety, Tolerability, and Pharmacokinetics of Escalating Doses ofRP-1127 (Glyburide for Injection) in Normal Male and Female Volunteers”(Study 101). The primary objective of this study was to evaluate thesafety and tolerability of different dose levels of RP-1127,administered as a bolus dose followed by a 3-day continuous infusionmaintenance dose. The secondary objective was to assess thepharmacokinetics and pharmacodynamic responses to RP-1127. Plasmaconcentrations of glyburide and its two major active metabolites, M1 andM2, were measured.

Five groups of patients were dosed, totaling 26 patients on drug (8 at17.3 μg bolus plus 0.4 mg/day, 16 at 130 μg bolus plus 3.0 mg/day, 1 at260 μg bolus plus 6.0 mg/day and 1 at 433 μg bolus plus 10.0 mg/day) and8 on placebo. Blood glucose was measured throughout the study, both toobtain pharmacodynamic information as well as for safety reasons. Thedosing regimen was a bolus over 2 minutes followed by a continuousinfusion for 72 hours.

TABLE 2 Dose Levels in Phase 1 Bolus Hourly Day 1 Day 2 and Dose DoseDose Day 3 Doses Number of Patients (μg) (μg/hr) (mg) (mg) RP-1127Placebo Total 17.3 16.7 0.417 0.4, 0.4 8 2 10 130.3 125.0 3.130 3.0, 3.016 4 20 260.0 250.0 6.260 6.0, 6.0 1 1 2 433.0 416.6 10.433 10.0, 10.0 11 2 Total 26 8 34

All plasma concentration data were analyzed by nonlinear regression,simultaneously incorporating drug behavior during and after theinfusion. Results are provided in Table 3

Pharmacokinetic parameters of RP-1127 were independent of dose, weight,height, body surface area, gender and age.

TABLE 3 Pharmacokinetic Parameters of RP-1127 (Glyburide for Injection)from Study 101 Pharmacokinetic parameters of RP-1127 0.4 and 3.0 mg/day(Glyburide for Injection) (N = 26) T_(1/2α(hr)) 0.44 T_(1/2β(hr)) 3.31V₁ Liters 6.0 Liters/kg 0.088 Liters/m² 3.36 V_(d) Liters 25.3 Liters/kg0.38 Liters/m² 14.3 Clearance mL/min 95 mL/min/kg 1.44 mL/min/m² 54As can be seen in Table 2, the pharmacokinetics of RP-1127 weregenerally consistent with those of other formulations of i.v. glyburidepresented in Table 1. However, following the initial bolus loading dose,there was a drop in plasma glyburide concentration, with a minimumreached at a median of 1.25-1.5 hours after commencement of dosing.Plasma glyburide levels increased thereafter, and achieved steady stateat approximately 8-20 hours following bolus administration. Steady statewas maintained for the remainder of the infusion.

FIG. 1 shows the mean plasma glyburide concentrations measured inpatients receiving 0.4 mg/day of glyburide.

The mean steady state glyburide concentration (C_(ss)) at 0.4 mg/day was3.8 ng/mL, and the maximum glyburide concentration (C_(max)) was 7.2ng/mL, which occurred at hour 72. Within one hour of treatment cessationmean glyburide plasma levels were reduced by 54% (from 4.4 ng/mL to 2.0ng/mL). Glyburide plasma levels for 50% of the patients were below thelimits of detection (0.5 ng/mL) by hour 76 and in 100% of patients byhour 96.

FIG. 2 shows the mean plasma glyburide concentrations measured inpatients receiving 3 mg/day of glyburide.

For the 3 mg/day dose, mean C_(ss) was 25.3 ng/mL and C_(max) (of allindividual subjects) was 50.7 ng/mL, which occurred in one patient athour 48. Within 1 hour of cessation of dosing, mean glyburide plasmalevels were reduced by 57% (from 27.3 ng/mL to 11.9 ng/mL). Glyburideplasma levels were below the limits of detection in 50% of the subjectsby hour 84 and in 100% of patients by hour 96.

FIG. 3 shows the mean plasma glyburide concentrations measured inpatients receiving 6 mg/day of glyburide. Dosing was stopped early, ataround 32 hours due to the hypoglycemic effect of the drug.

FIG. 4 shows the mean plasma glyburide concentrations measured inpatients receiving 10 mg/day of glyburide. Dosing was stopped early, ataround 24 hours due to the hypoglycemic effect of the drug.

Blood Glucose/Hypoglycemia Data

FIG. 5 shows the median blood glucose levels in patients receivingplacebo (no glyburide), 0.4 mg/day glyburide, and 3 mg/day glyburide. Ascan be seen, the 0.4 mg/day dose had a very minor but visible effect onBG and the 3.0 mg/day dose had a more pronounced effect, withouthypoglycemia (prolonged BG<70 mg/dL or signs/symptoms of hypoglycemiae.g. shakiness, anxiety, nervousness, palpitations, tachycardia,sweating, feeling of warmth, coldness, clamminess, dilated pupils,feeling of numbness “pins and needles”, hunger, nausea, vomiting,abdominal discomfort, headache, impaired judgment, fatigue, weakness,apathy, lethargy, confusion, amnesia, dizziness, delirium, blurredvision, double vision, difficulty speaking, slurred speech, and in moresevere cases seizures and coma).

From H0 to H8 the single subject receiving 250 μg bolus plus 6 mg/day ofintravenous glyburide experienced a gradual lowering of blood glucoselevels, however these remained above 70 mg/dL. Between approximately H8and H12, blood glucose levels dropped lower, and ranged from 59 to 72mg/dL. At approximately H13.3, the Subject intermittently displayedsigns of hypoglycemia in the form of sweating (diaphoresis) and hunger.These symptoms lasted 15 minutes. Blood glucose measurements at H14 andH 15 were within normal ranges, however from approximately H16 to H29blood glucose fluctuated between 49 and 134 mg/dL. During this periodthe subject was treated with food PRN but experienced intermittentsymptoms of hypoglycemia and at times felt shaky, lightheaded withtunnel vision, and clammy. Subject felt “shaky” and was diaphoreticwhile eating lunch, and so at approximately H29, the subject was treatedwith IV dextrose (10%) at a rate of 100 cc/hour, following which bloodglucose remained in the range 64-123 mg/dL. Dosing with study drug wassuspended at H32 as a result of continued clinical signs ofhypoglycemia. The D10 rate was decreased at BR34 to 50 cc/hr and wasreplaced with IV D5W at approximately HR 36. IV D5W was continued untilH48, at which time the patient had been consistently normoglycemic forapproximately 7 hours.

Total calories consumed by mouth and IV on day 2 by subject 402 was4309. The percentage of Kcals: Protein=11%; Carbs=66%; fat=23%.

During this episode, subject had classic symptoms of hypoglycemia butwas always alert, oriented and conversant. Subject was also able toconsume all food and liquids provided.

Dosing was stopped early, at around 32 hours due to the hypoglycemiceffect of the drug.

At H12 the BG was <70 mg/dL (68 mg/dL) and the glyburide plasma levelwas 64 ng/mL.

The subject receiving 433 μg bolus plus 10 mg/day glyburide experiencedblood glucose levels in the range 63 mg/dL-81 mg/dL from HI to H8, whichreduced in the 52-53 mg/dL range during H12- H22. The subject wastreated PRN throughout this time with the following: glucose gel,yogurt, apple juice, a bagel and peanut butter. At hour 22, the morningserum glucose below 50 mg/dL at which point dosing was suspended. Duringthis episode, subject had classic symptoms of hypoglycemia but wasalways alert, oriented and conversant. Subject was also able to consumeall food and liquids provided.

Dosing was stopped early, at around 24 hours due to the hypoglycemiceffect of the drug.

At hour 2, BG was below 70 mg/dL and the glyburide plasma level was57.94 ng/mL.

Discussion

Applicant believes that the results disclosed herein provide, for thefirst time, the results of experiments in which glyburide has beenadministered for more than a few hours and that plasma levels ofglyburide have been recorded. Garrel et al. (1987) administered a 1 mgi.v. bolus dose, followed by 0.3 mg/h for 17 hours, to six subjects withtype I diabetes (insulin-dependent diabetes mellitus (IDDM)); the totaldose was 6.1 mg glyburide. However, no PK analysis was performed.

Thus, it is believed that no-one has previously observed or describedthe effects with glyburide described herein.

Applicant notes that severe hypoglycemia occurred at 6 mg/day ofglyburide and 10 mg/day of glyburide delivered as continuous infusions(250 μg/hr and 17 μg/hr). It appears that glyburide levels of aboveabout 50 ng/mL, and probably in the range about 58-64 ng/mL or above aresufficient to cause hypoglycemia that is clinically relevant and/orrefractory to treatment. It was surprisingly difficult to treat thehypoglycemia caused by the continuous infusion at high doses (6 and 10mg/day) while maintaining glyburide administration. It is preferred toavoid hypoglycemia, for example, when treating a subject suffering fromacute stroke (ischemic and hemorrhagic), traumatic brain injury (TBI),spinal cord injury (SCI), myocardial infarction (MI), shock (includinghemorrhagic shock), organ ischemic, and ventricular arrhythmias.Accordingly, plasma levels of glyburide of less than about 50 ng/mL arepreferred plasma levels, providing the therapeutic benefits of glyburidewhile avoiding most or all of the deleterious side effects that higherconcentrations might cause (e.g., hypoglycemia). Preferentially,glyburide levels of about 10 ng/mL to about 20 ng/mL, or of about 20ng/mL to about 30 ng/mL, or of approximately 25 ng/mL should betargeted, it being understood that by doing so, a wide concentrationrange (up to approximately 50 ng/mL at peak) of glyburide in the bloodstream can be expected, at least for short periods of time.

An important point to note is that in acute conditions where intravenousglyburide is likely to be administered e.g. acute stroke (ischemic andhemorrhagic), traumatic brain injury (TBI), spinal cord injury (SCI),myocardial infarction (MI), shock, organ ischemia, and ventriculararrhythmias, the time window during which injury, cell death, or othercell, tissue, or organ damage is maximal is likely to be within about0-4, or about 0-6, or about 0-12, or about 0-24 hours. Thus attainingthe desired glyburide plasma levels quickly is vital. Furthermore inthese indications, hypoglycemia can have negative effects, thus it ispreferably to treat patients with doses of intravenous glyburide thatwill not cause extended or clinically significant hypoglycemia.

Furthermore, the difficulty experienced in treating hypoglycemia withoral and iv glucose indicates that the concept of increasing glyburidedoses into the hypoglycemic range and then cotreating with glucose maynot work. It has been known for some time that carbohydrate “loading”can cause substantial elevations in serum ALT and AST that generallybecome evident within 1 week of the diet change (Irwi et al1969, Porikoset al. 1983, Purkins et al. 2003, Kechagieas et al. 2008). Carbohydrateinduced aminotransferase elevations are frequently associated withsubstantial increases in serum triglycerides, probably resulting fromincreased synthesis of triglyceride in the liver. Deposition of glycogenin hepatocytes is also associated with elevations in serumaminotransferases and this has been described in poorly controlleddiabetes (Sayuk et al. 2007, Chatila et al. 1996). Glycogen depositionin the liver could occur quite quickly and may therefore account, atleast in part, for aminotransferase elevations observed withcarbohydrate loading. It also seems likely that the hyperinsulinemiceffect of glyburide would exacerbate the carbohydrate uptake andconversion to glycogen by the liver.

There is evidence from our study outlined in the above rationale i.e.that continued administration of large amount of carbohydrate inparallel to significant increases in insulin release leads to transientelevations in ALT and AST—this was experienced by the subject receiving6 mg/day glyburide, who was treated with 4,309 calories over 24 hoursand two thirds of this was in the form of carbohydrates. This is a verysubstantial carbohydrate load, far exceeding the daily carbohydrateintake employed in prior healthy volunteer studies that havedemonstrated aminotransferase elevations.

While these types of ALT and AST elevations caused by carbohydrateloading are not considered dangerous in normal healthy patients, theyare not preferable, especially in labile patients such as ones sufferingfrom acute conditions and should be avoided.

1. (canceled)
 2. A method of administering glyburide to a subject,comprising: (a) a first bolus administration of glyburide; (b) a firstcontinuous infusion administration of glyburide after the first bolusadministration of glyburide, wherein the first continuous infusionglyburide is administered at a first rate of administration for a firstperiod of time; and (c) a second continuous infusion administration ofglyburide after the first continuous infusion of glyburide wherein inthe second continuous infusion glyburide is administered at a secondrate of administration for a second period of time; wherein theglyburide is administered to the subject over a period of time, andwherein the subject is in need of treatment for stroke, traumatic braininjury, spinal cord injury, myocardial infarction, shock, organischemia, ventricular arrhythmias, ischemic injury, or hypoxia/ischemia.3. The method of claim 2, wherein the first and second rate ofadministrations are each about 15 μg/hr and about 300 μg/hr.
 4. Themethod of claim 2, wherein the total amount of glyburide administeredduring administration is less than about 10 mg per day.
 5. The method ofclaim 2, wherein the total amount of glyburide administered duringadministration is less than about 6 mg per day.
 6. The method of claim2, wherein the total amount of glyburide administered duringadministration is less than about 3.5 mg per day.
 7. The method of claim2, wherein the total amount of glyburide administered duringadministration is less than about 3 mg per day.
 8. The method of claim2, wherein the first rate of administration is greater than the secondrate of administration.
 9. The method of claim 8, wherein the firstperiod of time is about 1 hour to about 10 hours.
 10. The method ofclaim 9, wherein the second period of time is a period of time of about1 hour to about 10 hours.
 11. The method of claim 2, wherein the methodis used to treat acute stroke, traumatic brain injury, spinal cordinjury, myocardial infarction, shock, organ ischemia, ventriculararrhythmias, ischemic injury, hypoxia/ischemia, or other injuries,conditions, and disorders.
 12. The method of claim 2, wherein the firstcontinuous infusion has a rate of about 150 μg/hr to about 175 μg/hr ofglyburide for a period of time of about 6 hours.
 13. The method of claim12, wherein the second continuous infusion has a rate of about 100 μg/hrto about 125 μg/hr glyburide.
 14. The method of claim 13, wherein thesecond continuous infusion is administered over a period of time ofabout 66 hours, and where the sum of the first continuous infusion andof the second continuous infusion total a period of time of about 72hours.
 15. The method of claim 2, wherein the first bolus administrationdelivers about 125 μg to about 150 μg glyburide.
 16. The method of claim2, wherein the second bolus administration delivers about 125 μg toabout 150 μg glyburide.
 17. The method of claim 2, wherein the firstcontinuous infusion administration has a rate of about 15 μg/hr to about300 μg/hr glyburide.
 18. The method of claim 2, wherein the secondcontinuous infusion administration has a rate of about 15 μg/hr to about300 μg/hr glyburide.
 19. The method of claim 2, wherein the first bolusadministration comprises administration of about 130 μg of glyburidefollowed by the first infusion of about 163 μg/hr glyburide for 6 hoursfollowed by the second infusion of about 112 μg/hr glyburide for 66hours.
 20. The method of claim 2, further comprising: (d) a thirdcontinuous infusion administration of glyburide, after the secondcontinuous infusion of glyburide wherein the third continuous infusionof glyburide is administered at a third rate of administration for athird period of time.
 21. The method of claim 20, wherein the period oftime is about 1 hour to about 72 hours.